Please answer these questions thoroughly and to the best of your knowledge.

Do you have any of the following conditions? *

Epilepsy/seizures

Bleeding/clotting disorder

Heart disease

Asthma/emphysema

High blood pressure

Diabetes

OTHER

NONE

If you answered OTHER - describe your condition below:

Have you ever been told that your SNORING is serious enough that it can disturb others? *

Do you have any allergies (food, environmental, medication)? *

Known Food Allergies (if any):

List any medications taken on a daily basis: *

(If you do not currently take medications, also let us know in this section.)

Do you have any other medical condition of which Illuman Colorado should be aware? *

(describe any other medical conditions here)

Will you have any special medical requirements during the MROP? *

If you answered YES above, please describe:

Signature

By typing you name in this field you are confirming all the above information is correct. I hereby release the above information for use of the MROP staff, site staff, and/or any other Medical personnel who might need to provide care to me during this event. (This form will be at the registration check-in for your "wet" signature.) *

Today's Date *

Today's Date

MM

DD

YYYY

Thank you very much for completing the Illuman Colorado Medical Form. This is essential for ensuring the health and safety of every man participating in the upcoming MROP in Woodland Park, CO. Your responses will be kept confidential and a representative will be contacting you regarding any special needs or requests.

If you have not already done so, please also complete the Travel Form.